Quality Measures

Specialty Measure Set

#1 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

Description :

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period

NQS Domain :

Effective Clinical Care

Measure Type :

Intermediate Outcome

High Priority Measure :

Yes

#46 Medication Reconciliation Post-Discharge

Description :

The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record. This measure is reported as three rates stratified by age group: Reporting Criteria 1: 18-64 years of age Reporting Criteria 2: 65 years and older Total Rate: All patients 18 years of age and older

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

Yes

#47 Care Plan

Description :

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

Yes

#110 Preventive Care and Screening: Influenza Immunization

Description :

Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

NQS Domain :

Community/Population Health

Measure Type :

Process

High Priority Measure :

No

#111 Pneumococcal Vaccination Status for Older Adults

Description :

Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.

NQS Domain :

Community/Population Health

Measure Type :

Process

High Priority Measure :

No

#112 Breast Cancer Screening

Description :

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2

NQS Domain :

Community/Population Health

Measure Type :

Process

High Priority Measure :

No

#130 Documentation of Current Medications in the Medical Record

Description :

Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.

NQS Domain :

Patient Safety

Measure Type :

Process

High Priority Measure :

Yes

#131 Pain Assessment and Follow-Up

Description :

Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

NQS Domain :

Community/Population Health

Measure Type :

Process

High Priority Measure :

No

#154 Falls: Risk Assessment

Description :

Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months

NQS Domain :

Patient Safety

Measure Type :

Process

High Priority Measure :

Yes

#155 Falls: Plan of Care

Description :

Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

Yes

#182 Functional Outcome Assessment

Description :

Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user

NQS Domain :

Community/Population Health

Measure Type :

Process

High Priority Measure :

No

#236 Controlling High Blood Pressure

Description :

Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period

NQS Domain :

Effective Clinical Care

Measure Type :

Intermediate Outcome

High Priority Measure :

Yes

#240 Childhood Immunization Status

Description :

Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday

NQS Domain :

Community/Population Health

Measure Type :

Process

High Priority Measure :

No

#305 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

Description :

Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis. b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

No

#317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Description :

Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

NQS Domain :

Community/Population Health

Measure Type :

Process

High Priority Measure :

No

#318 Falls: Screening for Future Fall Risk

Description :

Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.

NQS Domain :

Patient Safety

Measure Type :

Process

High Priority Measure :

Yes

#367 Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use

Description :

Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

No

#374 Closing the Referral Loop: Receipt of Specialist Report

Description :

Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

No

#402 Tobacco Use and Help with Quitting Among Adolescents

Description :

The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

NQS Domain :

Community/Population Health

Measure Type :

Process

High Priority Measure :

No

#414 Evaluation or Interview for Risk of Opioid Misuse

Description :

All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user